PPO II - EmblemHealth

2013 Evidence of Coverage for PPO II
Chapter 9: What to do if you have a problem or complaint
(coverage decisions, appeals, complaints)
Legal
Terms
Th e formal name for the “Independent Review Organization” is the “Independent
Review Entity.” It is sometimes called the “IRE.”
Step 1: We will automatically forward your case to the Independent Review
Organization.
• We are required to send the information for your Level 2 Appeal to the Independent Review
Organization within 24 hours of when we tell you that we are saying no to your fi rst appeal. (If
you think we are not meeting this deadline or other deadlines, you can make a complaint. Th e
complaint process is diff erent from the appeal process. Section 10 of this chapter tells how to
make a complaint.)
Step 2: The Independent Review Organization does a “fast review” of your
appeal. The reviewers give you an answer within 72 hours.
• Th e Independent Review Organization is an independent organization that is hired by
Medicare. Th is organization is not connected with our plan and it is not a government agency.
Th is organization is a company chosen by Medicare to handle the job of being the Independent
Review Organization. Medicare oversees its work.
• Reviewers at the Independent Review Organization will take a careful look at all of the
information related to your appeal of your hospital discharge.
• If this organization says yes to your appeal, then we must reimburse you (pay you back) for
our share of the costs of hospital care you have received since the date of your planned discharge.
We must also continue the plan’s coverage of your inpatient hospital services for as long as it
is medically necessary. You must continue to pay your share of the costs. If there are coverage
limitations, these could limit how much we would reimburse or how long we would continue to
cover your services.
• If this organization says no to your appeal, it means they agree with us that your planned
hospital discharge date was medically appropriate.
� Th e notice you get from the Independent Review Organization will tell you in writing
what you can do if you wish to continue with the review process. It will give you the
details about how to go on to a Level 3 Appeal, which is handled by a judge.
Step 3: If the Independent Review Organization turns down your appeal, you
choose whether you want to take your appeal further.
• Th ere are three additional levels in the appeals process after Level 2 (for a total of fi ve levels of
appeal). If reviewers say no to your Level 2 Appeal, you decide whether to accept their decision
or go on to Level 3 and make a third appeal.
• Section 9 in this chapter tells more about Levels 3, 4, and 5 of the appeals process
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